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Iran has done what the United Kingdom has not dared: it has devised a single exam to be taken by its 20,000 doctors who are competing for 1600 residency positions. The UK system seemed to me unfair, but then an Iranian doctor explained Iran’s system. Rather than the UK’s online medical training application service (MTAS), set up in 2007 to rank medical students according to their 150 word answers about teamwork, prioritisation skills, and professional behaviour, Iran has one simple exam. Held yearly, it comprises 200 multiple choice questions that cover all aspects of clinical medicine, from psychiatry to ophthalmology. Unsurprisingly, just to pass this exam can take 2-3 years of 10 hours’ training a day. Whether those 6000 hours cooped up over books actually makes you a better doctor is debatable because it is difficult to gain any clinical experience during this critical time in training.

The specialty you join depends on your score, with paediatrics requiring a lower mark than surgery, for example. Problems arise because ranking devalues those specialties at the bottom. Specialties with lower pass marks become less popular because they are seen as “cop-out specialties.” Inevitably, all but in the highest echelon feel dissatisfied.

Controversially, rankings for training posts are not solely dependent on achievement in this exam. Doctors are further discriminated into four classes: A—female, B—you or a first degree relative is a veteran of the Iran-Iraq war, C—two years’ work as a rural general practitioner, and D—the rest.

In most specialties, 50% of positions are reserved for female doctors, and they will be accepted if they get 90% of the mark of group D (see CMAJ 2002;166:645). War veterans in contrast only have to get 80% of the mark achieved by non-combatants, as a sign of appreciation for their fighting. The same applies to doctors who have spent more than two years working as general practitioners in a rural area. The unfairness of this method is compounded by the fact that the number of applicants in class D is roughly equal to those in A, B, and C; therefore, competition among Iranian men is fierce.

So are UK medical students justified in their furore over MTAS? British medical students argue that ranking students in each university into fourths is unfair because different medical schools have different criteria and different standards of achievement. But these concerns pale into insignificance in comparison with what Iranian medical students experience. At least UK medical students can partly control their ranking, whereas Iranian medical students cannot decide their sex or whether their relatives chose to fight in a war. Would you prefer the Iranian or British system?

Miriam Longmore is a second year medical student at Somerville College Oxford.

I was wondering whether this article has any political agenda behind it. In any case, the comparison between the two systems is not relevant. You cannot compare a bad situation (for UK students) with a worse situation (for iranian students) if you want to have a constructive attitude to make changes for the better in UK. You should always look up for finding solutions and not down.

maya

What is the big deal about Iran?? India has been having these common entrance exam for over 15-20 years- where after internship one is expected to sit a common entrance exam and put your choices down for you sepciality. Your score, caste, income and lot of other issues come in to the mix before you are given your “residency choice”.
And what about USMLE? Every US doctor and FMG goes through the process of those steps and apply for specialties.
MTAS is still in its infancy and is still teething.
Where as NHS depends quite a lot on the training doctors to provide services to people even sometimes at the cost of training, other countries don’t. But the health isn’t anything to compare with the NHS either. There are positives and negatives on all sides.
MTAS needs to be a little more honest in its approach instead of “appearing” to be equal and fair to all- when it clearly isn’t.

Andrew Rogers

What a ridiculous article. Just because a one country (in this case, effectively a democratic dictatorship) happens to have an unfair application system doesn’t mean we should have to accept a slightly-less-unfair system. Academic standing IS important, and frankly, a national ranking exam does seem like a more sensible way of comparing the relative academic abilities of applicants than the current quartile ranking strategy. Combine this with a system where non-academic clinical attributes are also taken into account, then I believe we’d starting to approach a fairer and more balanced system.

ibn Sina

just a comment on Maya's remarks

most American junior residents DO have to provide significant clinical services – I have worked in both systems UK/USA(Chicago) and US residents see more patients, work longer hours, hardly get any weekends off and NO ONE ever goes off on sick leave!!!